Local Application

Application for Local Board Membership

clip0002.WMF (119736 bytes)

Local Association	Dues
Anne Arundel County	$35.00
Baltimore City, County, Howard	Inactive-No Dues at this time.
Carroll, Allegeny, Frederick, Garrett	$30.00
Eastern Shore	Inactive-No Dues at this time.
Montgomery/Prince Georges	Inactive-No Dues at this time.
Southern Maryland	Inactive-No Dues at this time.

We the undersigned, individual members of the firm or officers of the Corporation as named above, each agree to abide by the Constitution, By-Laws, Rules and Regulations of : The Independent Insurance Agents of ____________________________________, and to the Code of Ethics of the Independent Insurance Agents of America, Inc. and the Insurance Laws in the State of Maryland, if and when admitted to membership.

Name:_____________________________________________

Date:____________________

References: IIAM Members:

Name:_____________________
Agency:
Phone Number:_

DUES ARE NOT REFUNDABLE!

Application for Local Board Membership

Local Association

Dues

Anne Arundel County

$35.00

Baltimore City, County, Howard

Inactive-No Dues at this time.

Carroll, Allegeny, Frederick, Garrett

$30.00

Eastern Shore

Inactive-No Dues at this time.

Montgomery/Prince Georges

Inactive-No Dues at this time.

Southern Maryland

Inactive-No Dues at this time.

Trade Name of Firm:

Business Address

TelephoneFaxE-mail

Corporation Officers: #1 #2

#3 #4

Is the principal time devoted to insurance? Yes No

Are all members of the firm actively engaged in insurance? Yes No

What are their other activities and what % of income is derived from that activity?

List companies represented as an Agent:

List Premium Volume for last calendar year

Name:_____________________________________________

Name:_____________________________________________

Name:_____________________________________________

Name:_____________________________________________

Date:____________________

References: IIAM Members:

Name:_____________________
Agency:
Phone Number:_

Name:_____________________
Agency:
Phone Number:_

Have you completed your application for State Association Membership. Click here for the application!

Application for Local Board Membership

Local Association

Dues

Anne Arundel County

$35.00

Baltimore City, County, Howard

Inactive-No Dues at this time.

Carroll, Allegeny, Frederick, Garrett

$30.00

Eastern Shore

Inactive-No Dues at this time.

Montgomery/Prince Georges

Inactive-No Dues at this time.

Southern Maryland

Inactive-No Dues at this time.

Trade Name of Firm:

Business Address

TelephoneFaxE-mail

Corporation Officers: #1 #2

#3 #4

Is the principal time devoted to insurance? Yes No

Are all members of the firm actively engaged in insurance? Yes No

What are their other activities and what % of income is derived from that activity?

List companies represented as an Agent:

List Premium Volume for last calendar year

Name:_____________________________________________

Name:_____________________________________________

Name:_____________________________________________

Name:_____________________________________________

Date:____________________

References: IIAM Members:

Name:_______________________________________________________ Agency:______________________________________________________ Phone Number:_____________________

Name:_______________________________________________________ Agency:______________________________________________________ Phone Number:_____________________

Have you completed your application for State Association Membership. Click here for the application!

Name:_____________________
Agency:
Phone Number:_

Name:_____________________
Agency:
Phone Number:_